ResouRces



sAFe-T drew upon the American Psychiatric Association

Practice Guidelines for the Assessment and Treatment of
Patients with Suicidal Behaviors http://www.psychiatryonline.com/
pracGuide/pracGuideTopic_14.aspx
Practice Parameter for the Assessment and Treatment of Children and
Adolescents with Suicidal Behavior. Journal of the American Academy
of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s

SAFE-T
Suicide Assessment Five-step
Evaluation and Triage
1
IDeNTIFY RIsK FAcToRs
Note those that can be
modified to reduce risk

AcKNoWLeDGMeNTs
n

Originally conceived by Douglas Jacobs, MD, and developed as

a collaboration between Screening for Mental Health, Inc. and
the Suicide Prevention Resource Center.

2
IDeNTIFY PRoTecTIVe FAcToRs
Note those that can be enhanced

3
coNDucT suIcIDe INQuIRY

National Suicide Prevention Lifeline

1-800-273-TALK (8255)

Suicidal thoughts, plans,

behavior, and intent

4
DeTeRMINe RIsK LeVeL/INTeRVeNTIoN
Determine risk. Choose appropriate
intervention to address and reduce risk

http://www.sprc.org

5
DocuMeNT
Assessment of risk, rationale,
intervention, and follow-up

HHS Publication No. (SMA) 09-4432 CMHS-NSP-0193

Printed 2009

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical
change; for inpatients, prior to increasing privileges and at discharge.
1. RISK FACTORS
3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality
disorders, conduct disorders (antisocial behavior, aggression, impulsivity)
Co-morbidity and recent onset of illness increase risk
3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations
3 Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization
3 Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health statusreal
or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation
3 change in treatment: discharge from psychiatric hospital, provider or treatment change
3 Access to firearms

2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk
3 Internal: ability to cope with stress, religious beliefs, frustration tolerance
3 external: responsibility to children or beloved pets, positive therapeutic relationships, social supports

3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent

3 Ideation: frequency, intensity, durationin last 48 hours, past month, and worst ever
3 Plan: timing, location, lethality, availability, preparatory acts
3 Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions
3 Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious.
Explore ambivalence: reasons to die vs. reasons to live

* For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition
* Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above

4. RISK LEVEL/INTERVENTION
3 Assessment of risk level is based on clinical judgment, after completing steps 13
3 Reassess as patient or environmental circumstances change

RISK LEVEL

RISK/PROTECTIVE FACTOR

SUICIDALITY

POSSIBLE INTERVENTIONS

High

Psychiatric diagnoses with severe

symptoms or acute precipitating event;
protective factors not relevant

Potentially lethal suicide attempt or

persistent ideation with strong intent or
suicide rehearsal

Admission generally indicated unless a significant

change reduces risk. Suicide precautions

Moderate

Multiple risk factors, few protective

factors

Suicidal ideation with plan, but no intent

or behavior

Low

Modifiable risk factors, strong protective

factors

Thoughts of death, no plan, intent, or

behavior

Admission may be necessary depending on risk

factors. Develop crisis plan. Give emergency/crisis
numbers
Outpatient referral, symptom reduction.
Give emergency/crisis numbers

(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)

5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant
others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.